- Email: [email protected]
AFTERMATH OF STERILISATION
87
then move on. They show that embolism can recur in the same vessel, so that multiple emboli may produce effects in the same territory; and the histological picture shows that a clot can propagate along the whole length of a vessel and end in small white filaments that appear to consist of platelets. Perhaps more important than this confirmation of possibilities is the fact that Ross RUSSELL has actually watched a distal microembolus appear and traverse a retinal artery and then fragment, this process being accompanied by temporary loss of vision. He has separated this feature clearly from the stagnation or cattle-trucking" of blood in these arteries; and he has shown that the white matter consists of solid material, mainly in the form of platelet masses. Of equal importance is the fact that during his careful observations he did not see vasospasm. It is reasonable to infer that similar distal platelet microembolisation may occur intermittently in the cerebral cortex and give rise to transient ischxmic attacks in patients with more proximal thrombotic arterial occlusion, either embolic or non-embolic. It would not be reasonable to suggest that this is the only cause of such attacks, but it is probably the only cause that has been clearly demonstrated by the safe and simple means of ophthalmoscopy. Clearly, further observations are needed in patients with transient retinal or cerebral ischamlic episodes. "
Annotations ARTHROPOD-BORNE VIRUSES
small intracellular parasites which can within living susceptible cells. The survival of a virus in Nature depends on a series of successful transfers from one susceptible host to another. With most animal viruses, the second host is another animal of the same, or at least a very closely related, species. Different hosts may be infected, but these are usually " dead-end " infections which contribute nothing to the long-term propagation of the virus. The arthropodborne viruses are a notable exception to this general rule. They undergo two completely separate cycles of multiplication-one in a vertebrate (usually a warm-blooded animal or bird), and the other in an invertebrate-a blood-sucking arthropod which becomes infected when it feeds on an infected vertebrate. Direct animal-to-animal and arthropod-to-arthropod transmission takes place in Nature and can be reproduced in the laboratory; but the normal chain of infection which maintains the virus in Nature involves alternate cycles in vertebrate and invertebrate hosts. With most arthropod-borne viruses man is not the principal vertebrate host: exceptions are the viruses of epidemic yellow fever and dengue. Usually human infections result from chance contact between man and a mosquito or other arthropod which has become infected by feeding on a forest animal. In man these viruses may give rise to fatal hepatitis (as in some cases of classical yellow fever), meningitis or encephalitis, or a mild febrile disorder sometimes associated with a rash. One virus may produce very different clinical conditions in different patients, and different viruses may give rise to indis-
VIRUSES
are
reproduce themselves only
tinguishable illnesses.
In infections the assistance of correct diagnosis, and the
arthropod-borne-virus laboratory is essential for interpretation of results is complicated by serological interrelationships between viruses which may come from completely different ecological backgrounds and may produce entirely different illnesses in
most a
man.
growth of knowledge of this group of viruses may be judged from the fact that some 150 are now recognised, compared with only about 30 twenty years ago. A W.H.O. publication1 deals with the various methods by which the presence of arthropod-borne viruses may be detected, including antibody studies on human and animal populations of the region and the isolation of viruses from man or from vertebrate or arthropod sources. Useful tables indicate the main serological groups, the principal arthropod vectors, the clinical syndromes, and the geographical distribution of the most important agents. The Rockefeller Foundation has given powerful support to studies on arthropod-borne viruses, both in its central laboratory in New York and in field laboratories which it maintains in collaboration with the medical departments of countries in the tropics. The President’s review for 19602 refers to the increasing role of tissue-culture methods, by means of which many arthropod-borne viruses can be cultivated without recourse to mice. The Belem virus laboratory, which the Rockefeller Foundation has run in association with the Special Service of Public Health of Brazil, has been particularly successful in its studies in the Amazon region. No less than 32 different arthropod-borne viruses have been isolated by this laboratory, half of them from man. Some of these are known elsewhere, but several have not yet been detected outside South America. In India, where the Foundation supports a virus laboratory in Poona, attempts have been made to control the spread of Kyasanur forest disease, a tick-borne virus infection, by the use of a killed vaccine prepared against the closely related virus of Russian spring-summer encephalitis. Apparently, however, the R.S.S.E. vaccine had no effect on the incidence of the disease or on the severity of the infection in vaccinated individuals. India has also suffered severely from epizootics in horses caused by the virus of African horse sickness, which is transmitted by culicoides. The Indian strains of virus are somewhat different from the seven known African serotypes, much in the same way as the Indian tick-borne virus differs from the other tick-borne viruses. Arthropod-borne viruses, which have now been detected in every continent, affect, besides man, a very wide range of wild and domestic animals and birds, and may be carried by almost every sort of blood-sucking arthropod. Casals,3 of the Rockefeller Foundation laboratories, has aptly termed them " the versatile parasites ". The
AFTERMATH OF STERILISATION
INTERFERENCE with the reproductive functions of other people has always aroused strong emotion; and growing knowledge of inheritance, the decline of the degeneration theory, and mass misuse by the Nazis placed deliberate sterilisation under a cloud of suspicion. In Britain sterilisation is occasionally carried out (far more often, probably, in women than in men) for medical reasons and, less 1.
2. 3.
Tech. Rep. Wld Hlth Org. no. 219. 1961. Pp. 68. (Obtainable from Stationery Office at 5s.) Rockefeller Foundation Annual Report 1960: President’s Review. Casals, J. Trans. N.Y. Acad. Sci. 1957, 19, 219.
H.M.
88 for social reasons. The three Scandinavian countries have permitted sterilisation on a wider scale than most others. A Swedish Act of 1941 permits the operation on either sex for eugenic reasons (transmission of hereditary disorder), social reasons (mental or antisocial disorder making a person unsuitable to care for children), and medical reasons (if a pregnancy would seriously endanger life or health). Simple socioeconomic grounds are excluded. Over the past decade mixed medicosocial grounds have come to the fore. From Sweden Ekblad1 now reviews a 5-6-year follow-up of 225 women who had been sterilised.
frequently,
The 225 women lived in Stockholm and applied in 1951 to be sterilised on psychiatric or eugenic grounds or on the ground of " weakness "-the life of none was likely to be endangered by pregnancy. In only 7% had there been no pregnancy in the background, and 85% were in fact legally aborted and sterilised at the same time. 26% had had at least one legal abortion previously, and 8% admitted to at least one illegal abortion. 90% were over 30, but 6% were not yet 26 at the time of sterilisation; 15% were unmarried or living apart from their husbands. Psychosis and suicide among the parents were frequent; a third of the women had grown up in incomplete or broken homes, and 87% had had the minimum of education. But the husbands of the 193 married women did not seem to be at any particular social or psychiatric disadvantage. 5% of the women had no children (in all of these abortion and sterilisation were carried out at the same time), 38% had one or two, and 13% had over four. Threequarters of the women were of average intelligence and 18% below average, though none to imbecile level. Psychosis played a part in only about 1 % of cases, and 40% were judged normal in personality and intelligence-reflecting the weight which was in practice allowed to socioeconomic factors. 31 % were judged neurotic, and 20% of abnormal personality, but only 8% had had psychiatric treatment.
At
follow-up, four groups could be discerned. Most (78%) were wholly satisfied with the operation; and a further 4%, though troubled by it, had no regrets. On the other hand 11% had partial regrets, though " not to any noteworthy extent "; and 7% were more or less deeply disturbed by the sterilisation (though none to the point of social incapacity), and wished it had never been women
done.
In 5 of the 15
women
in this last group, hind-
sight showed that the operation probably was wrongly undertaken; but this could not be said, in Ekblad’s opinion, of any of the others. Assessing the factors which correlated with an unsatisfactory outcome the study confirmed the importance of youth (the danger is less after 30) and childlessness-only 1 of the 12 childless women fell in the " entirely satisfied " group. Where pressure or persuasion had been exerted there tended to be more regrets. While neurotic women (including those with fear of pregnancy) were more troubled by sterilisation, they had no more regrets than others; but women with abnormal personalities were more inclined to wish it had not been done. Low intelligence (contrary to the findings in some studies) did not apparently influence the outcome adversely-though the numbers were small. Ill effects, which usually took the form of depression and irritability, were least likely in those who continued in a stable and harmonious marriage. 20% of the 225 attributed menstrual disturbances to the operation, and 19% reported vague pains and tiredness as a direct consequence. 16% complained of an unsatisfied desire for children; but Ekblad believes that it is impossible to identify maternal traits in the personality as a contraindi1. The Prognosis after Sterilisation on Social-Psychiatric Grounds. MARTIN EKBLAD. Acta psychiat. scand. 1961, 37, suppl. 161. Pp.
By 162.
cation in advance of the operation. Capacity for sexual satisfaction was increased in most of those who reported change. None showed sexual promiscuity after the operation. 3 of the women had undergone plastic procedures to restore fertility, and 1 had become pregnant. This report shows that, if sterilisation is to be considered, careful thought should be given to possible contraindications-notably youth and childlessness. On the other hand, too much weight may often be given to the risk of psychological complications. Indeed preoccupation with this risk may cause the operation to be denied to those handicapped people who need it most. COLISTIN
SEVERE infections due
to gram-negative bacteria are an important reason is the and 1 2; becoming of these organisms to the usual antiirregular sensitivity biotics.3 For example, infections by the pseudomonas species often develop in debilitated patients under treatment with broad-spectrum antibiotics.4 The poor prognosis in these infections has led to a search for more effective antimicrobial substances. Colistin, first isolated by Koyama 5 from Bacillus colistinus, is a polypeptide antibiotic with a structure very similar to that of polymyxin B.Yow et al. have carried out laboratory tests with 226 bacterial strains in order to define the antibacterial spectrum of colistin. They found that all strains of Pseudomonaspyocyanea and some strains of Aerobacter aerogenes and Escherichia coli were sensitive to concentrations of the antibiotic which could be expected in the blood after intramuscular injection of a moderate dose. In contrast, only a few strains of the proteus and gram-positive bacteria tested were sensitive to similar concentrations. These findings, which accord with those of other workers,8 9 point to the close similarity between the spectrum of colistin and of polymyxin B. In an attempt to evaluate colistin clinically the same workerstreated 83 patients, most of whom had infections caused by gram-negative bacteria, with intramuscular injections of the antibiotic. Almost all these patients had previously been treated unsuccessfully with other antibiotics, and many were seriously ill. Assessment of the value of colistin was difficult because these debilitated patients, many of whom had organic abnormalities, were susceptible to superinfection by colistin-resistant bacteria. Nevertheless, there were some clear successes. One patient with pseudomonas septicaemia responded to intramuscular colistin, and another, with pseudomonas meningitis, to combined intramuscular and intrathecal therapy. It has previously been suggested that an important advantage of colistin over polymyxin B is its lower neuroand nephro- toxicity, and Yow et al. provide further evidence of this. No definite nephrotoxicity, drug fever, or other serious side-effect occurred in any of the 83 patients who received colistin; but 3 patients had transient perioral parsesthesiae, and 1 had vertigo which did not recur when the drug was continued at a lower dosage. commoner
Finland, M., Jones, W. F., Jr., Barnes, M. W. J. Amer. med. Ass. 1959, 170, 2188. Rogers, D. E. New Engl. J. Med. 1959, 261, 677. Waisbren, B. A. Arch. intern. Med. 1951, 88, 467. Curtin, J. A., Petersdorf, R. G., Bennett, I. L. Ann. intern. Med. 1961, 54, 1077. 5. Koyama, Y. J. Antibiot. 1950, 3, 457. 6. Biserte, G., Dautrevaux, M. C.R. Soc. Biol., Paris, 1957, 151, 1888. 7. Yow, E. M., Tan, E., Shane, L., Schonfeld, S., Abu-Nassar, H. Arch. intern. Med. 1961, 108, 664. 8. Hirsch, H. A., McCarthy, G. C., Finland, M. Proc. Soc. exp. Biol., N.Y. 1960, 103, 338. 9. Petersdorf, R. G., Hook, E.W. Bull. Johns Hopk. Hosp. 1960, 107, 133. 1.
2. 3. 4.
then move on. They show that embolism can recur in the same vessel, so that multiple emboli may produce effects in the same territory; and the histological picture shows that a clot can propagate along the whole length of a vessel and end in small white filaments that appear to consist of platelets. Perhaps more important than this confirmation of possibilities is the fact that Ross RUSSELL has actually watched a distal microembolus appear and traverse a retinal artery and then fragment, this process being accompanied by temporary loss of vision. He has separated this feature clearly from the stagnation or cattle-trucking" of blood in these arteries; and he has shown that the white matter consists of solid material, mainly in the form of platelet masses. Of equal importance is the fact that during his careful observations he did not see vasospasm. It is reasonable to infer that similar distal platelet microembolisation may occur intermittently in the cerebral cortex and give rise to transient ischxmic attacks in patients with more proximal thrombotic arterial occlusion, either embolic or non-embolic. It would not be reasonable to suggest that this is the only cause of such attacks, but it is probably the only cause that has been clearly demonstrated by the safe and simple means of ophthalmoscopy. Clearly, further observations are needed in patients with transient retinal or cerebral ischamlic episodes. "
Annotations ARTHROPOD-BORNE VIRUSES
small intracellular parasites which can within living susceptible cells. The survival of a virus in Nature depends on a series of successful transfers from one susceptible host to another. With most animal viruses, the second host is another animal of the same, or at least a very closely related, species. Different hosts may be infected, but these are usually " dead-end " infections which contribute nothing to the long-term propagation of the virus. The arthropodborne viruses are a notable exception to this general rule. They undergo two completely separate cycles of multiplication-one in a vertebrate (usually a warm-blooded animal or bird), and the other in an invertebrate-a blood-sucking arthropod which becomes infected when it feeds on an infected vertebrate. Direct animal-to-animal and arthropod-to-arthropod transmission takes place in Nature and can be reproduced in the laboratory; but the normal chain of infection which maintains the virus in Nature involves alternate cycles in vertebrate and invertebrate hosts. With most arthropod-borne viruses man is not the principal vertebrate host: exceptions are the viruses of epidemic yellow fever and dengue. Usually human infections result from chance contact between man and a mosquito or other arthropod which has become infected by feeding on a forest animal. In man these viruses may give rise to fatal hepatitis (as in some cases of classical yellow fever), meningitis or encephalitis, or a mild febrile disorder sometimes associated with a rash. One virus may produce very different clinical conditions in different patients, and different viruses may give rise to indis-
VIRUSES
are
reproduce themselves only
tinguishable illnesses.
In infections the assistance of correct diagnosis, and the
arthropod-borne-virus laboratory is essential for interpretation of results is complicated by serological interrelationships between viruses which may come from completely different ecological backgrounds and may produce entirely different illnesses in
most a
man.
growth of knowledge of this group of viruses may be judged from the fact that some 150 are now recognised, compared with only about 30 twenty years ago. A W.H.O. publication1 deals with the various methods by which the presence of arthropod-borne viruses may be detected, including antibody studies on human and animal populations of the region and the isolation of viruses from man or from vertebrate or arthropod sources. Useful tables indicate the main serological groups, the principal arthropod vectors, the clinical syndromes, and the geographical distribution of the most important agents. The Rockefeller Foundation has given powerful support to studies on arthropod-borne viruses, both in its central laboratory in New York and in field laboratories which it maintains in collaboration with the medical departments of countries in the tropics. The President’s review for 19602 refers to the increasing role of tissue-culture methods, by means of which many arthropod-borne viruses can be cultivated without recourse to mice. The Belem virus laboratory, which the Rockefeller Foundation has run in association with the Special Service of Public Health of Brazil, has been particularly successful in its studies in the Amazon region. No less than 32 different arthropod-borne viruses have been isolated by this laboratory, half of them from man. Some of these are known elsewhere, but several have not yet been detected outside South America. In India, where the Foundation supports a virus laboratory in Poona, attempts have been made to control the spread of Kyasanur forest disease, a tick-borne virus infection, by the use of a killed vaccine prepared against the closely related virus of Russian spring-summer encephalitis. Apparently, however, the R.S.S.E. vaccine had no effect on the incidence of the disease or on the severity of the infection in vaccinated individuals. India has also suffered severely from epizootics in horses caused by the virus of African horse sickness, which is transmitted by culicoides. The Indian strains of virus are somewhat different from the seven known African serotypes, much in the same way as the Indian tick-borne virus differs from the other tick-borne viruses. Arthropod-borne viruses, which have now been detected in every continent, affect, besides man, a very wide range of wild and domestic animals and birds, and may be carried by almost every sort of blood-sucking arthropod. Casals,3 of the Rockefeller Foundation laboratories, has aptly termed them " the versatile parasites ". The
AFTERMATH OF STERILISATION
INTERFERENCE with the reproductive functions of other people has always aroused strong emotion; and growing knowledge of inheritance, the decline of the degeneration theory, and mass misuse by the Nazis placed deliberate sterilisation under a cloud of suspicion. In Britain sterilisation is occasionally carried out (far more often, probably, in women than in men) for medical reasons and, less 1.
2. 3.
Tech. Rep. Wld Hlth Org. no. 219. 1961. Pp. 68. (Obtainable from Stationery Office at 5s.) Rockefeller Foundation Annual Report 1960: President’s Review. Casals, J. Trans. N.Y. Acad. Sci. 1957, 19, 219.
H.M.
88 for social reasons. The three Scandinavian countries have permitted sterilisation on a wider scale than most others. A Swedish Act of 1941 permits the operation on either sex for eugenic reasons (transmission of hereditary disorder), social reasons (mental or antisocial disorder making a person unsuitable to care for children), and medical reasons (if a pregnancy would seriously endanger life or health). Simple socioeconomic grounds are excluded. Over the past decade mixed medicosocial grounds have come to the fore. From Sweden Ekblad1 now reviews a 5-6-year follow-up of 225 women who had been sterilised.
frequently,
The 225 women lived in Stockholm and applied in 1951 to be sterilised on psychiatric or eugenic grounds or on the ground of " weakness "-the life of none was likely to be endangered by pregnancy. In only 7% had there been no pregnancy in the background, and 85% were in fact legally aborted and sterilised at the same time. 26% had had at least one legal abortion previously, and 8% admitted to at least one illegal abortion. 90% were over 30, but 6% were not yet 26 at the time of sterilisation; 15% were unmarried or living apart from their husbands. Psychosis and suicide among the parents were frequent; a third of the women had grown up in incomplete or broken homes, and 87% had had the minimum of education. But the husbands of the 193 married women did not seem to be at any particular social or psychiatric disadvantage. 5% of the women had no children (in all of these abortion and sterilisation were carried out at the same time), 38% had one or two, and 13% had over four. Threequarters of the women were of average intelligence and 18% below average, though none to imbecile level. Psychosis played a part in only about 1 % of cases, and 40% were judged normal in personality and intelligence-reflecting the weight which was in practice allowed to socioeconomic factors. 31 % were judged neurotic, and 20% of abnormal personality, but only 8% had had psychiatric treatment.
At
follow-up, four groups could be discerned. Most (78%) were wholly satisfied with the operation; and a further 4%, though troubled by it, had no regrets. On the other hand 11% had partial regrets, though " not to any noteworthy extent "; and 7% were more or less deeply disturbed by the sterilisation (though none to the point of social incapacity), and wished it had never been women
done.
In 5 of the 15
women
in this last group, hind-
sight showed that the operation probably was wrongly undertaken; but this could not be said, in Ekblad’s opinion, of any of the others. Assessing the factors which correlated with an unsatisfactory outcome the study confirmed the importance of youth (the danger is less after 30) and childlessness-only 1 of the 12 childless women fell in the " entirely satisfied " group. Where pressure or persuasion had been exerted there tended to be more regrets. While neurotic women (including those with fear of pregnancy) were more troubled by sterilisation, they had no more regrets than others; but women with abnormal personalities were more inclined to wish it had not been done. Low intelligence (contrary to the findings in some studies) did not apparently influence the outcome adversely-though the numbers were small. Ill effects, which usually took the form of depression and irritability, were least likely in those who continued in a stable and harmonious marriage. 20% of the 225 attributed menstrual disturbances to the operation, and 19% reported vague pains and tiredness as a direct consequence. 16% complained of an unsatisfied desire for children; but Ekblad believes that it is impossible to identify maternal traits in the personality as a contraindi1. The Prognosis after Sterilisation on Social-Psychiatric Grounds. MARTIN EKBLAD. Acta psychiat. scand. 1961, 37, suppl. 161. Pp.
By 162.
cation in advance of the operation. Capacity for sexual satisfaction was increased in most of those who reported change. None showed sexual promiscuity after the operation. 3 of the women had undergone plastic procedures to restore fertility, and 1 had become pregnant. This report shows that, if sterilisation is to be considered, careful thought should be given to possible contraindications-notably youth and childlessness. On the other hand, too much weight may often be given to the risk of psychological complications. Indeed preoccupation with this risk may cause the operation to be denied to those handicapped people who need it most. COLISTIN
SEVERE infections due
to gram-negative bacteria are an important reason is the and 1 2; becoming of these organisms to the usual antiirregular sensitivity biotics.3 For example, infections by the pseudomonas species often develop in debilitated patients under treatment with broad-spectrum antibiotics.4 The poor prognosis in these infections has led to a search for more effective antimicrobial substances. Colistin, first isolated by Koyama 5 from Bacillus colistinus, is a polypeptide antibiotic with a structure very similar to that of polymyxin B.Yow et al. have carried out laboratory tests with 226 bacterial strains in order to define the antibacterial spectrum of colistin. They found that all strains of Pseudomonaspyocyanea and some strains of Aerobacter aerogenes and Escherichia coli were sensitive to concentrations of the antibiotic which could be expected in the blood after intramuscular injection of a moderate dose. In contrast, only a few strains of the proteus and gram-positive bacteria tested were sensitive to similar concentrations. These findings, which accord with those of other workers,8 9 point to the close similarity between the spectrum of colistin and of polymyxin B. In an attempt to evaluate colistin clinically the same workerstreated 83 patients, most of whom had infections caused by gram-negative bacteria, with intramuscular injections of the antibiotic. Almost all these patients had previously been treated unsuccessfully with other antibiotics, and many were seriously ill. Assessment of the value of colistin was difficult because these debilitated patients, many of whom had organic abnormalities, were susceptible to superinfection by colistin-resistant bacteria. Nevertheless, there were some clear successes. One patient with pseudomonas septicaemia responded to intramuscular colistin, and another, with pseudomonas meningitis, to combined intramuscular and intrathecal therapy. It has previously been suggested that an important advantage of colistin over polymyxin B is its lower neuroand nephro- toxicity, and Yow et al. provide further evidence of this. No definite nephrotoxicity, drug fever, or other serious side-effect occurred in any of the 83 patients who received colistin; but 3 patients had transient perioral parsesthesiae, and 1 had vertigo which did not recur when the drug was continued at a lower dosage. commoner
Finland, M., Jones, W. F., Jr., Barnes, M. W. J. Amer. med. Ass. 1959, 170, 2188. Rogers, D. E. New Engl. J. Med. 1959, 261, 677. Waisbren, B. A. Arch. intern. Med. 1951, 88, 467. Curtin, J. A., Petersdorf, R. G., Bennett, I. L. Ann. intern. Med. 1961, 54, 1077. 5. Koyama, Y. J. Antibiot. 1950, 3, 457. 6. Biserte, G., Dautrevaux, M. C.R. Soc. Biol., Paris, 1957, 151, 1888. 7. Yow, E. M., Tan, E., Shane, L., Schonfeld, S., Abu-Nassar, H. Arch. intern. Med. 1961, 108, 664. 8. Hirsch, H. A., McCarthy, G. C., Finland, M. Proc. Soc. exp. Biol., N.Y. 1960, 103, 338. 9. Petersdorf, R. G., Hook, E.W. Bull. Johns Hopk. Hosp. 1960, 107, 133. 1.
2. 3. 4.